Thursday, January 29, 2009

African Americans & the US Hospice Model

Cancer has a paper about treatment preferences and hospice enrollment, focusing on African Americans. The data comes from structured interviews with 300 cancer patients at a single cancer center, which included questions about treatment preferences as well as self-reported need/interest in home services. Consonant with other research (for instance this recent paper in JAGS demonstrating higher rates of hospitalization and ICU use at the end of life amongst African Americans), African American patients reported a greater willingness to undergo cancer treatments with a low likelihood of benefit in the last 6 months of life, compared with white Americans. African Americans also reported a greater interest in and assigned higher utility to hospice services (the services weren't described specifically as 'hospice' services, but instead different home services provided by hospice care were described separately), although this difference seemed to be mostly due to economic status (and disappeared when controlling for economic hardship).

The authors conclude that African American cancer patients' needs, at least as described by this study, aren't particularly met by the current US hospice model. They are less likely to be eligible for hospice care (using these treatment preferences as a proxy for eligibility since you technically have to forswear life-prolonging treatments to be eligible for hospice under the Medicare Hospice Benefit), yet have self-reported needs for hospice services which are higher in general than white Americans (even if this is largely due to economic hardship and need). These issues are certainly not unique to African Americans; these data however support the idea that these issues are accentuated for them. They conclude:

For 25 years, hospice services have been restricted to patients in the last 6 months of life who are willing to give up curative treatment. Although this restriction was intended to control costs, it has substantially reduced access to hospice for many patients who have needs for hospice services, and a disproportionate number of these patients are African American. This eligibility criterion should be reconsidered, and needs-based criteria should be considered to make hospice eligibility criteria both fairer and more consistent with eligibility criteria for other health insurance benefits.
Obviously this is what the 'home-palliative care' and 'open-access hospice' models have been trying to address and we'll see how successful these movements are, and given the economic climate (and Medicare floating the idea of paying less for patients with longer stays despite everyone for a long time beating the drum to try to increase hospice lengths of stay) it seems highly unlikely that the needs of sick, symptomatic patients receiving chemotherapy are going to be met by our current and future hospice models. This would be fine if we had another robust system in place, but we don't (at least nationally - the Kaiser home palliative care model and others are available to some in certain areas), and so we muddle along.

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